The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

Bahamian doctors yesterday expressed concern that the Government was attempting to “sucker us into” accepting National Health Insurance (NHI) by adjusting the model slightly to accommodate some of their demands.

The Christie administration, during a Monday meeting with the Medical Association of the Bahamas (MAB), backtracked sightly on both its NHI care model and how doctors would be compensated under the scheme.

Its discussion paper prepared for that meeting, and responding to MAB concerns, pledged that the so-called Patient Centre Medical Home (PCMH) model that NHI is striving to impose in the Bahamas would “not be mandatory”.

The document, which has been obtained by Tribune Business, also promised that doctors could opt not to be paid for NHI-related services via the capitation method - a set annual per patient fee.

However, as ever, the Government briefing paper contained a ‘sting in the tail’ for any doctor wanting to be compensated by NHI on a ‘fee for services’ basis, as opposed to the preferred capitation method.

It warned that Bahamian doctors who elect not to adopt the Patient Centre Medical Home (PCMH) model, and remain independent primary care providers, will “not be eligible for additional financial benefits”.

These benefits, the document says, will include “up front” payments for PCMH doctors, plus “subsidised” medical malpractice insurance, “start-up funds” and performance-based bonuses.

One doctor, speaking to Tribune Business on condition of anonymity due to fears of victimisation, described the Government’s approach as “almost Mafia-like”.

“If we don’t play ball with them today, they won’t play ball with us tomorrow,” the physician said of the Government’s latest NHI proposal.

They added that it appeared to be another classic ‘divide and conquer’ tactic, which governments of both colours have used to overcome private sector opposition, with the latest NHI proposal seeking to drive a wedge between PCMH doctors and those who remained as primary care providers.

Questioning where the Government was going to find the additional funds to pay for the PCMH ‘inducements’, the doctor said it appeared that it was trying to ‘damp down’ NHI opposition long enough to facilitate the scheme’s implementation. And, once in, they suggested the Government would seek to foist the PCMH model on all.

“This part of that divide and conquer,” the doctor said of the Government’s latest NHI moves. “They’re going to entice some of us, and split us apart.

“They’ve tweaked it [the NHI model] to try and make us feel a little bit better. Just sucker us into it, and then they’ll put the hammer down.”

The Government’s discussion paper, in a seeming concession to Bahamian doctors, said: “Upon concerns raised by the MAB and some physicians, we have proposed that enrolment as a medical home will NOT be mandatory.

“Individual physicians will be allowed to enroll with National Health Insurance Commission (NHIC) as certified primary care providers (PCP), offering services that are in the PHC (primary health care) package but paid on a fee for service basis.”

Then came the ‘catch’, as the Government also agreed that doctors did not have to accept the ‘capitation’ method of payment, provided they met “key” NHI certification criteria.

While agreeing that the extent of healthcare reforms proposed by NHI, both in their financing and service provision, could not be achieved overnight, the Government paper said: “There will be early adapters who are not afraid of change and willing to evolve in order to improve the product delivered to their patients through the utilisation of the Medical Home concept.

“Those providers will be able to receive the additional financial benefits that will be available to the Medical Homes. For those providers not willing to initially participate as Medical Homes, they can choose to remain as independent clinicians working in a non-interdisciplinary environment.

“However, they will not be eligible for additional financial benefits that will be dependent upon moving towards a model that has been shown to be tremendously more effective than the current one which exists in country.”

Those benefits include a “fixed, steady flow of income paid up front to the medical home based on the enrolled population”, whereas those not adopting the PCMH model will not receive ‘up front’ payment.

Further PCMH benefits being ‘dangled as a carrot’ in front of doctors include “subsidised malpractice insurance”; “pay for performance bonus based on population health”; and “start-up funds toward the certification as a medical home based on population enrolled and [size of facilities]”.

The Government paper also touted the PCMH model as superior to all others, saying: “We all agree that the current system does not work well for Bahamian patients as it currently exists. Neither in the public sector nor in the private sector.

“As such, to disregard all the international evidence from a multitude of cultures and countries which show that PCMH models of care improve patient outcomes and improve cost-effectiveness would be unfair to the Bahamian people.”

The MAB, though, in its original position paper submitted to the Prime Minister, warned that the PCMH model was essentially unproven, and studies were still being conducted to assess its effectiveness.

It warned that as a relatively new healthcare model, its benefits in terms of quality, patient experience and other indicators was “largely unknown”.

The letter to the Prime Minister also expressed fears over NHI’s ‘capitation’ payment system, which bundles payments to physicians together.

This, the MAB said, would require Bahamian physicians to manage a network of healthcare providers, while also being responsible for monitoring treatment quality and patient use - potentially compromising quality of care.

MAB members at Monday’s meeting were also told that the Government was determined to press ahead with its plans to create a publicly-owned health insurance company, which will compete with the private sector in the issuance of NHI Vital Benefits Package (VBP) policies.

“They have said they will have a public insurance company for sure. That seems to be a cornerstone of their programme,” one doctor told Tribune Business.

The Government plans to call its public insurer Bahama Care, Tribune Business was told, and press ahead with its formation despite strong opposition from the Bahamas Insurance Association (BIA).

Suggesting that the Government stick to regulation, the BIA suggested that a public insurer was unnecessary as part of NHI.

“Introducing a public insurer into the Bahamian market would duplicate efforts and deplete taxpayer funds. Major insurers already exist and have effectively provided healthcare benefits for tens of thousands of Bahamians over decades,” the BIA said.

“These companies operate in a regulated environment, without political involvement, which allows for policies and services to be administered fairly and in a non-partisan manner.

“The BIA’s framework for universal healthcare requires that all coverage be provided and administered by private health insurers. This will relieve the government of additional unnecessary bureaucracy, spur economic growth, and expand employment.”